Justice

The four common bioethical principles

The principle of justice could be described as the moral obligation to act on the basis of fair adjudication between competing claims. As such, it is linked to fairness, entitlement and equality. In health care ethics, this can be subdivided into three categories: fair distribution of scarce resources (distributive justice), respect for people’s rights (rights based justice) and respect for morally acceptable laws (legal justice) (Gillon, 1994). Alperovitch et al. (2009) describe two elements of the principle of justice, namely equality and equity.

The right to be treated equally, and in some cases equal access to treatment, can be found in many constitutions, but in actual practice, a number of different factors may influence actual access to treatment e.g. age, place of residence, social status, ethnic background, culture, sexual preferences, disability, legal capacity, hospital budgets, insurance cover and prognosis. The Swiss Academy of Medical Sciences recently reported that doctors and other medical staff are increasingly refusing to administer potentially useful treatment for economic reasons (SAMS, 2008) and there has been considerable debate in the UK over the refusal of expensive treatment to patients who would benefit from it (need reference here).

With regard to equality in the provision of care, some people are not treated with the same degree of respect as that accorded to others e.g. with indifference, unfriendliness, lack of concern or rudeness. Such attitudes, prejudice and discrimination may, in some cases, be a reflection of the stigmatization of people belonging to groups identified and devalued on the basis of a particular attribute (of which dementia is one example). Inequality and discrimination may also be based on structural violence such as racism, sexism and poverty (Mahajan et al., 2008) which Kelly (2006) describes as a form of discrimination based on unequal power relations.

Gillon (1994) emphasises that justice is more than mere equality in that people can be treated unjustly even if they are treated equally. With reference to Aristotle, he argues that it is important to treat equals equally and unequals unequally in proportion to the morally relevant inequalities (the criterion for which is still being debated). Situations will always arise where decisions have to be taken and there are limited resources, different options and/or other conflicting moral concerns. Care must be taken to ensure that health care resources are used sensibly and fairly. People with dementia are potentially vulnerable in that they are likely at some stage to be unable to state their preferences and ensure that they are respected. Advance directives at least provide written evidence of their wishes, which should go some way towards ensuring that they are not placed at a disadvantage to others when it comes to making crucial decisions about their health and well-being. Health care proxies could also play a useful role in ensuring that such decisions are taken into account and as far as possible respected.

Nevertheless, it is possible that a high degree of incapacity and increased vulnerability, perhaps combined with failure by others to recognise their personhood, may result in a lack of distributive justice. Nerney (undated) argues:

“Once individuals get reduced to a status where personal autonomy or self-determination is not "possible", they may lose their moral claim on our resources. Contemporary ethicists (…/…) make this claim on the principle of distributive justice. Distributive justice underlies our progressive tax system, e.g., and simply calls for sharing resources in ways that approximate fairness. Distributive justice has been the cornerstone upon which we argued for resources for the most vulnerable. Contemporary ethical theory has now turned this principle on its head. Because we live in times of scarce resources, especially medical and long term care resources, those who can "benefit" the least (read those with significant disabilities) may end up having the lowest moral claim on these resources.”